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Introduction:We aimed to evaluate differences in mortality between Coronavirus 2019 (COVID-19) patients without pneumothorax, with pneumothorax, and with pneumothorax requiring intervention.Secondarily, we ascertained whether size or method of intervention for pneumothorax provides insight into the poor prognosis associated with PTX.Methods: Data from adult patients from a large integrated health system constituting 21 medical centers whose first hospitalization for COVID-19 occurred between January 3, 2020 and December 31, 2022 were collected and divided into those with PTX and those without.Those with PTX were further subdivided into intervention (PTX I ), defined as pigtail catheter or tube thoracostomy placement, or no intervention (PTX O ).Baseline characteristics, comorbidities, vaccination status, intensive care unit (ICU) admission, and ventilatory assistance were compared among groups.Multivariable logistic regression analysis was performed to evaluate variable associations with in-hospital mortality.Propensity score analysis was conducted to adjust for potentially confounding factors between those receiving intervention versus no intervention. Results: We identified 38,107 patients.Incidence rate of PTX was 1.2% (487/38,107).Among patients with PTX, 78.8% (384/487) received intervention.Length of stay (LOS) was the highest in the PTX I group, second highest in the PTX O group, and lowest in the group without PTX (31.0 d, 22.2 d, and 6.8 d, respectively, P < 0.01).ICU admission rate was the highest in the PTX I group, lower in the PTX O group, and lowest in the group without PTX (353/384 or 91.9%, 73/103 or 70.9%, and 6324/37,620 or 16.8%, respectively, P < 0.001).Inhospital mortality rate was highest in the PTX I group, lower PTX O group, and lowest in the group without PTX (68.5% and 263/384, 63.1% and 65/103, 8.4% and 3143/37,620, respectively, P < 0.001).While 97% of patients with large pneumothoraces received intervention, only 50% of patients with small pneumothoraces received intervention.Small pneumothoraces were associated with worse in-hospital mortality (P = 0.04), but this difference was not seen in medium or large pneumothoraces.Large bore thoracostomy tube